Youth, Sport and Recreation Registration Form

This form is to register a child/ren in the Central Desert Regional Council YSR program by parents/guardians.

NOTES:

This registration is valid until you withdraw it in writing.
This form is also available in paper form at YSR forms.
You can withdraw your child's registration at any time by filling in this form.

Parent/Guardian details

Parent/Guardian Name: *

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Parent/Guardian Address:*

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Parent/Guardian Phone:*

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Parent/Guardian Email:

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Child one details

Primary community:*

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Child's Name: *

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Child's date of birth:*

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Child's gender:*

Female

Male

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Is the Child Aboriginal or Torres Strait Islander?*

Yes

No

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Does the Child have any special needs?*

Yes

No

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Please list special needs:*

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Does the child have any medical conditions we should know about?*

Yes

No

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Please list medical conditions:*

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Does the child have any allergies?*

Yes

No

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Please list allergies:*

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Would you like to add another child?

Yes

No

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Child two details

Primary community:*

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Child's Name: *

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Child's date of birth:*

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Child's gender:*

Female

Male

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Is the Child Aboriginal or Torres Strait Islander?*

Yes

No

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Does the Child have any special needs?*

Yes

No

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Please list special needs:*

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Does the child have any medical conditions we should know about?*

Yes

No

Invalid Input

Please list medical conditions:*

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Does the child have any allergies?*

Yes

No

Invalid Input

Please list allergies:*

Invalid

Would you like to add another child?

Yes

No

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Child three details

Primary community:*

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Child's Name: *

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Child's date of birth:*

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Child's gender:*

Female

Male

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Is the Child Aboriginal or Torres Strait Islander?*

Yes

No

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Does the Child have any special needs?*

Yes

No

Invalid Input

Please list special needs:*

Invalid Input

Does the child have any medical conditions we should know about?*

Yes

No

Invalid Input

Please list medical conditions:*

Invalid Input

Does the child have any allergies?*

Yes

No

Invalid Input

Please list allergies:*

Invalid

Would you like to add another child?

Yes

No

Invalid Input

Child four details

Primary community:*

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Child's Name: *

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Child's date of birth:*

Invalid Input

Child's gender:*

Female

Male

Invalid Input

Is the Child Aboriginal or Torres Strait Islander?*

Yes

No

Invalid Input

Does the Child have any special needs?*

Yes

No

Invalid Input

Please list special needs:*

Invalid Input

Does the child have any medical conditions we should know about?*

Yes

No

Invalid Input

Please list medical conditions:*

Invalid Input

Does the child have any allergies?*

Yes

No

Invalid Input

Please list allergies:*

Invalid

Note: if you want to add another child, please submit this form first and then resubmit it with the extra child/ren.

Emergency contact's details

Emergency contact name: *

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Emergency contact phone number:*

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Emergency contact relationship to the child/ren:*

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Declaration

I, *

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of *

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I agree for the child/children named above to be filmed/recorded/photographed and appear in visual and/or audio recordings which can be used in advertisements, documents, social media and other promotional material published by the Central Desert Regional Council, for the duration of their participation in CDRC programs and services, unless permission withdrawn prior.
I give permission for the name/s of the child/children named above, and visual and/or audio recordings of the child/children named above, to be used in advertisements, documents and other promotional material published by the Central Desert Regional Council on an ongoing basis, unless permission is withdrawn in writing.
I assign any rights I may have in the visual and/or audio recordings and associated advertisements, documents and promotional material to the Central Desert Regional Council.
I am free to enter into this Agreement, and for the child/children named above to appear in the proposed advertisements, documents and other promotional material published by the Central Desert Regional Council.
I understand that this authorisation will stand until withdrawn by me.
This Agreement is made under the laws of the Northern Territory, and any dispute can be taken for resolution by the courts in the Northern Territory.

Your Signature*

Sign Above

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CAPTCHA*

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